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LexisNexis has selected some recently issued noteworthy IMR decisions that illustrate the criteria that must be met to obtain authorization for a variety of different medical treatment modalities. LexisNexis Commentary for each selected IMR is provided below. Some of these IMR decisions were reprinted in California Compensation Cases, which can be accessed on Lexis Advance. The list includes how physicians should best apply treatment guidelines utilizing the “Medical Evidence Search Sequence” for the treatment of injured workers as set forth in 8 Cal. Code Reg. § 9792.21.1, and include the MTUS at 8 Cal. Code Reg. § 9792.21.1(d)(1), other medical treatment guidelines such as the ACOEM and ODG at 8 Cal. Code Reg. § 9792.21.1(d)(2) and peer reviewed studies at 8 Cal. Code Reg. § 9792.21.1(d)(3); requests for opioid medications and when the MTUS guidelines support their use; how patients should be monitored and weaned; when use of the generic rather than the name brand medication is justified; rehabilitation and transitional living programs in cases of traumatic brain injury; the standards that must be met to receive costs of transportation to and from medical appointments when an injured worker claims that he or she is unable to self-transport or use public transportation...read more.
■ 84 Cal. Comp. Cases 773. Cryotherapy—VascuTherm Rental—Knee Osteoarthritis and Surgery—IMR reviewer upheld UR decision allowing only 7 days of the requested 28-day VascuTherm rental with purchase of a thermal wrap for 50-year old applicants left knee, post-operatively. Applicant was undergoing treatment for severe tricompartmental osteoarthritis of the left knee. The ODG guidelines cited by the IMR reviewer recommend continuous-flow cryotherapy units for up to 7 days postoperatively. In upholding the UR modification of the treating physician’s request, the IMR reviewer noted that the treating physician did not provide rationale for VascuTherm use in excess of the guideline recommendations. Further, the IMR reviewer noted that the treating physician did not provide documentation as to why compression therapy was needed in addition to anticoagulation therapy to reduce the risk of blood clots. The IMR reviewer concluded that rental of the VascuTherm unit beyond the 7 days authorized by UR was not medically necessary based on the applicable guidelines.
LexisNexis Commentary: This IMR illustrates that a physician must provide a solid rationale to support treatment requests, particularly those that exceed the applicable guideline criteria.]
■ https://www.dir.ca.gov/dwc/imr/imr-decisions/IMR-Decisions2019/IMR-07012019/CM19-0091219.PDF. Computed Tomography (CT) Scan—Right Knee Osteoarthritis—Obesity—IMR reviewer overturned UR decision denying treating physician’s request for CT scan of 58-year old applicant’s right knee, where applicant had severe right knee osteoarthritis and was a candidate for knee arthroplasty. Applicant’s ability to exercise was limited due to her obesity, and she was unlikely to be able to lose weight without surgery. However, applicant’s situation was complicated by the fact that she needed to lose weight before surgery could be considered. The MTUS/ACOEM 2019 guidelines for knee disorders recommend CT scan for pre-surgical planning. The IMR reviewer in this case noted that although surgery had not yet been approved, applicant’s physician recommended that applicant undergo surgery after she lost weight and, therefore, the request for CT scan was medically necessary based on the guideline criteria. LexisNexis Commentary: This IMR decision discusses applicant’s need for weight loss prior to undergoing surgery for her industrial knee condition. Although surgery was not yet requested, a CT scan was necessary in preparation for future surgery.
■ 84 Cal. Comp. Cases 862. Opioid Medications—Hydromorphone and Kadian—IMR reviewer overturned UR decision reducing the quantity of Hydromorphone and Kadian ER requested by the treating physician to treat 62-year old applicant’s low back pain. According to applicant, her pain was reduced by more than half with use of opioid medication. The IMR reviewer cited the MTUS/ACOEM guidelines for opioid use for subacute and chronic pain, which require documentation of a successful opioid trial, an inadequate response to more appropriate evidence-based treatment approaches, at least 30 percent improvement in both pain and function with opioid use, and an opioid treatment agreement between doctor and patient. To support the medical necessity of prolonged opioid use under the guidelines, there must be documentation of continued functional benefit, regular urine drug screening and at least semiannual attempts to wean below 50mg MED. In this case, the treating physician documented ongoing 4As, urine drug screening, CURES assessment, and a current opioid consent. Applicant was on the lowest doses that allowed function, and weaning had been attempted. The IMR reviewer noted that because applicant was able to perform ADLs with use of the medication, there was objective improvement in her condition with use of Hydromorphone and Kadian. Therefore, the IMR reviewer concluded that the prescribed opioid medications were medically necessary under the applicable guidelines. The IMR reviewer emphasized that opioid treatment should not be abruptly halted without an appropriate weaning process. After finding that the prescribed opioid medications were medically necessary, the IMR reviewer commented that a UR/IMR recommendation for or against certain medical treatment based on the MTUS/ACOEM guidelines does not constitute a medical order for treatment or discontinuation of treatment, and that the treating physician must ultimately originate and initiate all medical orders regarding the patient’s care.
LexisNexis Commentary: This IMR decision involves a case where there is no issue as to the medical necessity of the requested medications, but rather a question as to whether applicant should get more pills or less pills in a single prescription. UR opted for less pills, and, with respect to the Kadian, substituted a lesser quantity of the generic version, which was presumably less expensive. The decision also emphasizes that improvement in pain and function must be documented to support continued use of opioid medications, and that gradual tapering, rather than abrupt cessation, of the medication is required to safely wean patients from opioids.]
■ 84 Cal. Comp. Cases 869. Opioid Medications—Tylenol With Codeine—IMR reviewer overturned UR decision denying treating physician’s request for prescription of Tylenol with codeine to treat 64-year old applicant’s chronic widespread pain with radiculopathy. Applicant had been using opioids for a while after she fell and sustained additional injuries, with consistent CURES results, pain contract and drug testing results. Oxycodone and Norco were trialed with improved pain and function but were discontinued due to skin rash. As noted by the IMR reviewer, the MTUS and ODG do not usually recommend opioids for chronic pain, breakthrough pain or neuropathic pain, but indicate that that they may be used for chronic severe pain in certain cases such as severe radiculopathy after other treatments have failed. The IMR reviewer concluded that applicant’s condition, which included severe chronic pain and radiculopathy, met the guideline criteria and, therefore, the request for Tylenol with codeine was medically necessary.
LexisNexis Commentary: This IMR decision addresses a situation where applicant was unable to tolerate more potent opioids and was prescribed Tylenol with codeine, which was sufficient to reduce pain and improve function.
■ 84 Cal. Comp. Cases 869. Prescription Medications—Anticonvulsants—Neurontin—IMR reviewer overturned UR decision reducing quantity of requested Neurontin by half and substituting name brand drug with generic equivalent, gabapentin 100mg. As noted by the IMR reviewer, the MTUS chronic pain guidelines moderately recommend anticonvulsants such as gabapentin for neuropathic pain as adjuncts to other medications. There is no specific recommendation for or against the use of gabapentin for radicular pain, but under the guidelines, a trial of gabapentin as a third- or fourth- line medication is reasonable. The MTUS also recommends gabapentin for an indefinite period to control chronic persistent pain. The IMR reviewer noted that in this case gabapentin was prescribed for applicant’s peripheral neuropathy sustained in a traumatic fall with facture of the radial head and concluded that applicant met the criteria for taking gabapentin for radiculopathy.
LexisNexis Commentary: This IMR decision is particularly helpful as the IMR reviewer provides links to the MTUS guidelines he relied upon in finding that the requested treatment was medically necessary.
■ https://www.dir.ca.gov/dwc/imr/imr-decisions/IMR-Decisions2019/IMR-07012019/CM19-0091300.PDF. Prescription Medications—Antidepressants/Anticonvulsants for Chronic Pain—Duloxetine/Topamax—IMR reviewer overturned UR decision denying treating physician’s request for antidepressant Duloxetine 30 mg #30, and anticonvulsant Topamax 100 mg #30, to treat applicant’s chronic pain. The MTUS/ACOEM 2019 guidelines cited by the IMR reviewer recommend Duloxetine for CRPS that is sufficient to require medication, especially if other modalities and medications have failed. Although anticonvulsants are generally not indicated, the guidelines state that they may be considered for severe, chronic CRPS as a fourth-line or fifth-line treatment, after strengthening exercises and medications (including NSAIDs, bisphosphonates and certain antidepressants) have failed, and that patients using these anticonvulsants for pain should be monitored for adverse effects. In this case, 54-year old applicant suffers from CRPS with cervical spine and upper extremity pain following industrial injury. The IMR reviewer noted that applicant is stable on her current medication regiment, that pain improvement was 60 percent (although there was no documentation of functional improvement), that applicant failed multiple other treatment modalities, and that applicant had been approved for a permanent spinal cord stimulator. The IMR reviewer indicated that discontinuing a stable medication prior to spinal cord stimulator placement would be counterproductive and, therefore, should be postponed until after treatment. Accordingly, the IMR reviewer concluded that the prescribed Duloxetine and Topamax met the MTUS/ACOEM criteria and were medically necessary. The IMR reviewer pointed, however, that “Topamax” is the brand name of topiramate, and that there is no medical necessity for use of brand name medication over the equivalent generic brand.
LexisNexis Commentary: The IMR reviewer in this case provided a good explanation as to why the requested prescriptions were medically necessary to treat applicant’s chronic pain pursuant to the applicable MTUS/ACOEM guidelines. Interestingly, the IMR reviewer noted that it is unwise to discontinue a stable medication prior to spinal cord stimulator placement, and also emphasized that there is no medical necessity for brand name medication where there is a cheaper generic version available.
PHYSICAL REHABILITATION/TRANSITIONAL LIVING
■ https://www.dir.ca.gov/dwc/imr/imr-decisions/IMR-Decisions2019/IMR-05012019/CM19-0061738.PDF. Outpatient Physical Rehabilitation/Transitional Living Program—Transportation Costs—IMR reviewer overturned UR decision denying provider’s request for 31-year old applicant with traumatic brain injury to attend outpatient treatment at a physical rehabilitation/transitional living day program for an unspecified duration. UR denied the request due to lack of documentation, and also denied the provider’s concurrent request for transportation costs to and from the program. The IMR reviewer noted that the MTUS traumatic brain injury 2017 guidelines recommend use of outpatient home and community-based rehabilitation for patients with traumatic brain injury. In this case, the documentation showed that applicant made significant gains in attention, memory and pain management after just a few weeks of attending an outpatient rehabilitation program. However, applicant continued to experience cognitive, visual and emotional deficits that presented potential risks to his ability to function independently and safely at home and in the community. Because applicant continued to improve with outpatient rehabilitation but had not made sufficient recovery nor learned how to transfer the rehabilitation exercises to his home setting in the short time attending the rehabilitation program, the IMR reviewer concluded that additional sessions to include up to 5 hours of therapy per day, twice per week for 3 weeks, plus associated transportation costs, was medically necessary.
LexisNexis Commentary: This IMR decision provides an example of a situation where applicant is benefitting from a particular treatment and additional treatment is necessary to maximize applicant’s improvement.
■ https://www.dir.ca.gov/dwc/imr/imr-decisions/IMR-Decisions2019/IMR-07012019/CM19-0092313.PDF. Transportation Costs—Medical Appointments—IMR reviewer overturned UR decision denying provider’s request for transportation to and from all medical appointments required by 54-year old applicant who suffered from chronic low back, knee, ankle, and shoulder pain following a 2006 industrial injury. According to applicant’s provider, applicant has missed office visits and injections due to a lack of transportation. Applicant indicated that she is able to stand and walk for 10-15 minutes without medications and 45 minutes with medications. She is currently out of work on disability. In approving medical transportation, the IMR reviewer cited the MTUS 2015 guidelines for knee disorders and the ODG knee injury section addressing transportation. The IMR reviewer noted that although the MTUS does not specifically address transportation, the guidelines recommend that patients with chronic knee pain avoid activities that substantially aggravate symptoms. Additionally, the ODG recommend medically necessary transportation to appointments in the same community for patients with disabilities preventing self-transport. The IMR reviewer determined that applicant’s treating physician provided evidence of significant functional deficits, including gait problems, on physical examination that would prevent applicant from using public transportation. Therefore, the IMR reviewer concluded that the request for medical transportation costs was medically necessary based on the applicable guidelines.
LexisNexis Commentary: This IMR decision is helpful to remind providers that they must document functional deficits limiting self-transport to get approval for medical transportation costs. In this case, applicant’s deficits prevented her using public transportation.
■ https://www.dir.ca.gov/dwc/imr/imr-decisions/IMR-Decisions2019/IMR-05012019/CM19-0035006.PDF. Transportation Costs—Medical Appointments—IMR reviewer overturned UR denial of treating physician’s request for transportation costs to 1 medical appointment. Here, 61-year old applicant was undergoing treatment for post-laminectomy syndrome, cervical spine radiculopathy, lumbar spine radiculopathy, traumatic brain injury, chronic pain syndrome, post-concussive syndrome, and left shoulder impingement syndrome, and required a home health aide to help him with his ADLs. In finding the requested transportation reasonable, the IMR reviewer cited the ODG, Knee and Leg Chapter under Transportation, which recommend medically necessary transportation to and from medical appointments for patients age 55 or older and in need of “a nursing home level of care.” Additionally, the IMR reviewer noted that Aetna’s guidelines allow reimbursement for medical transportation where there is documentation that the patient cannot travel alone and requires assistance of a nurse companion. The IMR reviewer concluded that applicant’s symptoms and diagnosis, which indicated disability, coupled with the treating physician’s discussion of applicant’s requirement of a home health aide, supported a finding that the request for medical transportation was reasonable and medically necessary under the guideline criteria.
LexisNexis Commentary: This IMR decision is helpful to alert treating physicians requesting transportation costs that they must explain that even if the injured worker is not living in a nursing home, they still need “a nursing home level of care” as described in the guidelines and, therefore, need transport to and from medical appointments.
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